Comparison of topical antifungal agents for oral candidiasis treatment: a systematic review and meta-analysis

Abstract

To compare the efficacy and safety of topical antifungal drugs for oral candidiasis in adults and children. Databases were searched from their inception to December 2020. The inclusion criterion was randomized controlled trials comparing topical antifungal agents. The primary outcomes were clinical response and mycological cure rates. The secondary outcomes were adverse reaction incidence and relapse rate. In adults with oral candidiasis, fluconazole showed a better clinical response rate than clotrimazole (P=0.001; risk ratio [RR], 1.14), but a similar mycological cure rate (P=0.57; RR, 1.03). There was no significant difference in clinical response and mycological cure rates with either fluconazole and amphotericin B (clinical: P=0.47, RR, 0.96; mycological: P=0.99, RR, 1.00) or with either itraconazole and clotrimazole (clinical: P=0.51, RR, 1.06; mycological: P=0.45, RR, 1.32). For immunocompetent patients, fluconazole was superior to clotrimazole in terms of clinical response rate. For immunosuppressed patients, clotrimazole and itraconazole presented similar clinical response and mycological cure rates, but the relapse rate with itraconazole was lower than that with clotrimazole. In infants, miconazole and nystatin showed similar clinical response rates (P=0.36; RR, 1.23), whereas miconazole presented a superior mycological cure rate (P=0.03; RR, 4.03). Fluconazole and amphotericin B are recommended as topical antifungal agents for adults with oral candidiasis. Existing studies tend to recommend fluconazole for immunocompetent patients and itraconazole for immunosuppressed patients, whereas miconazole is recommended for infants.